Overview
Traumatic injuries account for the majority of fractures, although some fractures are the result of
a disease process (pathologic fractures from cancer or osteoporosis). Fractures can be classified
as open (formerly called compound) or closed (formerly called simple) depending on
communication or noncommunication with the external environment. Fractures also may be
classified based on the fracture pattern (e.g., transverse, oblique) or by appearance (i.e.,
displaced, nondisplaced). In a displaced fracture the two ends of the broken bone are separated
from one another and out of their normal positions. Displaced fractures are usually comminuted
(more than two fragments) or oblique. In a nondisplaced fracture the periosteum is intact across
the fracture and the bone is still in alignment.
Manifestations of fractures include immediate localized pain, decreased function, and inability to
bear weight on or use the affected part. Goals of treatment are anatomic realignment of bone
fragments, immobilization to maintain realignment, and restoration of function of the injured
part. Most fractures heal without complications.
Objectives
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Identify relevant assessment data for a patient with musculoskeletal trauma.
Prioritize emergency nursing care of an intoxicated patient with musculoskeletal trauma.
Appropriately delegate nursing care of a patient with musculoskeletal trauma.
Differentiate various types of fractures.
Describe the interprofessional care of a patient after surgical repair for musculoskeletal
trauma.
Develop a plan of care for a patient with acute alcohol withdrawal.
Case Study
C.T. is a 32-year-old man who is brought to the emergency department (ED) by ambulance
following a motor vehicle crash. The paramedics report that it was a one-car accident in which
the patient veered off the road and hit the side rail along a bridge. He had his seat belt on and the
airbag deployed. The patient is drowsy but responds when questioned. He is admitted on a
backboard with cervical immobilization and immobilization of the left leg, which has an obvious
deformity of the tibia. The rescue team reports that the patient's wife has been called and is on
her way to the hospital. Blood for an alcohol level was taken in the ED as requested by the
police, a peripheral IV was started with normal saline, and his last vital signs taken 10 minutes
ago were BP 90/70, heart rate (HR) 122 beats/minute, respirations (R) 16 breaths/minute, and
oxygen saturation 94% (on oxygen at 2 L/min via nasal cannula).
1. An initial assessment of the patient is performed. In the primary survey, prioritize the
following assessments. Number the assessments below in priority order.
___2__ Breathing: Respiratory rate 18 breaths/minute, shallow; chest wall movement
symmetric; clear breath sounds
___3__ Circulation: Carotid pulse weak at 122 beats/minute; skin cool, face flushed
___4__ Disability: Patient is drowsy but answers questions appropriately. Oriented ×3.
Pupils are equal and react briskly. Glasgow score = 15
__1___ Alertness/Airway: Patient able to speak, intact gag reflex, left cheek and jaw swollen
and red
__5___ Exposure/Environmental Control: Remove patient's clothing/limit heat loss
__7___ Get resuscitation adjuncts (e.g., nasogastric tube, laboratory studies)
__6___ Facilitate adjuncts and family presence
2. Indicate which of the following interventions you would expect to implement while continuing
with the primary survey. There are 4 correct answers.
_____ Prepare for rapid-sequence intubation.
__X___ Take full set of vital signs, including temperature and oxygen saturation.
__X___ Start high-flow oxygen with non-rebreather mask.
_____ Insert an oropharyngeal airway.
_____ Release the cervical spine immobilization and turn the patient's head to the side.
__X___ Monitor ECG for heart rate and rhythm.
__X___ Pain assessment and management.
_____ Apply a pneumatic antishock garment.
3. When assessing C.T., you notice a strong odor of alcohol on his breath. A police officer has
accompanied C.T. to the ED. The lab results indicate that his blood alcohol concentration (BAC)
is 0.25 mg % (250 mg/dL). Your immediate concern for C.T. is the possibility of
_____ respiratory arrest
_____ vomiting with aspiration
_____ onset of withdrawal symptoms
_____ a need for larger doses of analgesics
Answer: Vomiting with aspiration. Vomiting frequently occurs with an elevated BAC. Because
C.T. is still on a backboard with cervical spine immobilization, an inability to use positional
changes to protect the airway during vomiting puts him at high risk for aspiration. Suction
equipment must be available for immediate use. Respiratory arrest could occur if the BAC
continues to rise but is not an immediate risk at a BAC of 0.15 mg %. If C.T. uses alcohol
chronically, withdrawal symptoms may start to occur in 4 to 6 hours following his last intake.
Cross-tolerance of alcohol with other CNS depressants would also occur.
4. The secondary survey to identify all of C.T.'s injuries is quickly completed. C.T.'s clothes have
been removed for a thorough physical assessment, and vital signs are taken once again. Because
C.T. has sustained significant trauma, additional interventions are also required at this time.
Select the interventions that would be indicated for C.T. There are 4 correct answers.
_X___ A focused abdominal sonography for trauma (FAST) to rule out abdominal bleeding
__X___ Chest x-ray to rule out pneumothorax, hemothorax, tension pneumothorax
___X__ Realignment and immobilization of the left lower extremity
_____ IV naloxone
_____ Placement of a central line for IV access
_____ CT scan of the head to rule out head injury from alcohol intoxication
_____ Laboratory studies for hemoglobin, hematocrit
__X___ Pain assessment
_____ Mechanical ventilation
Case Study continues:
The primary and secondary survey reveals that C.T. has a bruised and swollen left thigh in
addition to the fracture of the tibia, and he has difficulty opening his mouth because of the facial
injury. His heart rhythm indicates tachycardia, his BP is 104/68, his SpO2 is 96%, and 360 mL
urine returned on placement of the catheter. C.T.'s wife arrives at the ED and is anxious to see
her husband. She immediately asks if he is intoxicated. She tells you that this is the second
accident that he has had in the past year and that he has a long history of alcohol abuse. When
taken to see C.T., she begins yelling at him and tells him that this is the last straw. He closes his
eyes and won't talk to her. Then the transporter arrives to take C.T. for x-rays.
5. While C.T. is in x-ray, you take time to talk with his wife. Which response would be most
appropriate at this time?
a. “Are you angry with your husband?"
b. "Do you blame yourself for his accident?"
c. "I understand this must be a very difficult situation for you."
d. "Don't worry, we will get your husband the treatment he needs to stop drinking."
Answer:
C is correct! Therapeutic communication involves open-ended statements that encourage C.T.'s
wife to verbalize her concerns. Yes-or-no questions are not open-ended questions. You may give
the wife false hope because you cannot guarantee sobriety.
6. C.T. should go to x-ray with what equipment and personnel to maintain his safety?
a. IV and oxygen and unlicensed personnel
b. IV, oxygen, heart monitoring, and RN
c. IV, oxygen, heart monitoring with emergency drugs, and ACLS certified personnel
d. IV only and unlicensed personnel
Answer:
B is correct! C.T. requires monitoring by a trauma RN at all times. The IV fluids and oxygen are
necessary to maintain hemodynamic and respiratory stability. There is no indication that the
patient has risk factors for sudden lethal dysrhythmia; therefore no emergency drugs or ACLS
certified personnel are necessary for transfer to the x-ray department.
7. While the patient is being positioned for x-rays, he cries out in pain and complains of
increasing pain to his left leg. The nurse's first priority is to
a. give morphine as ordered for pain management.
b. reposition the leg for comfort.
c. reassess circulation, movement, and sensation distal to the injury of the left leg and notify
the ED physician of any changes.
d. stop the x-ray and transport the patient back to the emergency department immediately.
Answer:
C is correct! Reassessment of the injured extremity is essential to determining changes in
vascular or neurologic function. The x-rays are essential to proper diagnosis, so the x-rays should
not be discontinued unless the patient demonstrates an immediately life- or limb-threatening
condition. Morphine may be given as ordered, but the priority is reassessing circulation,
movement, and sensation. Once the reassessment is completed, the patient may be repositioned
for comfort.
8. C.T. returns from the x-ray department. The results indicate that he has displaced comminuted
fractures of the left femur and left tibia and a nondisplaced fracture of the left mandible. The
cervical vertebrae are intact, and no other fractures are identified. C.T. requires surgery to reduce
and immobilize the fractures of his tibia and femur. The orthopedic surgeon discusses the risks of
surgery with C.T. and his wife. You recognize that surgical risks for C.T. are increased because
a. acute alcohol withdrawal may be triggered by surgery
b. he will need decreased levels of anesthesia because of the synergistic effect of alcohol.
c. he will not be able to receive opioid analgesics perioperatively because of his depressed
respirations.
d. his BAC is so high that his level of consciousness cannot be determined.
Answer:
B is correct! The intoxicated patient needs decreased dosages of anesthetics and opioids because
of the synergistic effect of the alcohol. His respirations are not so low that these opioid agents
cannot be used. His level of consciousness (LOC) is depressed as an effect of the alcohol, but
LOC can be determined. Alcohol withdrawal delirium does not occur until 30 to 120 hours after
the last drink.
Case study continues:
C.T. is taken to surgery, where anesthesia is balanced with his blood alcohol level, and he is
admitted to the orthopedic unit following surgery. An open reduction and internal fixation with
compression plates was performed on his left tibia and left femur. A closed reduction of the
mandible was performed and the lower jaw was wired to the upper jaw.
9. Which nursing activities could you appropriately delegate to unlicensed assistive personnel
(UAP) (Select all that apply.)?
a. Obtain vital signs, including pulse oximetry.
b. Ensure that wire cutters are readily available at the bedside.
c. Assess C.T.'s airway and observe for signs of respiratory distress.
d. Elevate C.T.'s left leg on pillows.
e. Determine adequacy of C.T.'s nutritional intake.
Answer:
A, b, and d are correct! UAPs may appropriately perform activities that they can be trained to do,
such as obtaining vital signs and necessary equipment and elevating a patient's leg. Assessment
of a patient is not an appropriate responsibility to delegate to UAP.
10. C.T. is at risk for several complications of fractures. List them (hints are below).
a. __fat embolism_______________________________________
b. __compartment syndrome_______________________________________
c. ___venous thromboembolism______________________________________
Hints:
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This complication occurs most commonly with fractures of long bones, ribs, tibia, and
pelvis
This complication is commonly associated with fractures of the distal humerus and
proximal tibia and causes progressive pain unrelieved by drugs and out of proportion to
the level of injury.
Veins of lower extremities are extremely susceptible to this complication. Signs and
symptoms are difficult to differentiate in the patient with musculoskeletal injuries of the
lower extremities.
11. Five hours after C.T.'s admission to the orthopedic unit, he complains of increasing pain and
numbness and tingling in his left toes. Upon assessment, you find an absence of a left pedal
pulse, delayed capillary refill, and coolness and pallor of the leg below his fracture site. The most
appropriate action for you to take is to:
a. apply ice to the tibial fracture site.
b. reposition the leg so that the toes are lower than the thighs.
c. elevate leg with pillow so that the feet are higher than the thighs.
d. notify the health care provider immediately without repositioning the leg.
Answer:
D is correct! C.T. is experiencing manifestations of compartment syndrome, and the health care
provider should be notified immediately so that the fascia may be cut. Application of ice may
result in vasoconstriction and may exacerbate compartment syndrome, and elevation may lower
venous pressure and slow arterial perfusion. Time is muscle in this case, so delays in contacting
the HCP are unacceptable.
12. On the second postoperative day, you determine that C.T. is developing signs of alcohol
withdrawal. Select the signs that indicate alcohol withdrawal. There are 5 correct answers.
a. Anxiety and agitation
b. Diaphoresis
c. Malaise and headache
d. Tremulousness
e. Hallucinations (auditory or visual)
f. Hyporeflexia
g. Drowsiness
h. Increased heart rate and blood pressure
Answer: a, b, d, e, h
12. C.T.'s withdrawal symptoms are controlled with the administration of benzodiazepines.
While caring for him in an acute care setting, you recognize that
a. he is too ill to worry about his alcohol use at this time.
b. his addictive behavior may be helped with interventions intended to motivate change.
c. his addiction to alcohol should not be addressed until he is ready to be discharged.
d. he will require intensive inpatient treatment in a substance abuse facility following discharge
from the hospital.
Answer:
B is correct! While patients are in acute care settings, especially when their medical problems are
associated with substance abuse, the nurse is in a unique position to motivate and facilitate
addictive behavior change. Interventions should be used to increase the patient's awareness of the
problem and motivate the patient for behavior change. The addictive behavior should not be
ignored and must be addressed with the patient.